The Health and Disability Commissioner has taken several district health boards to task over poor referral systems that meant patients were lost in the health system.
In reports on three cases, Commissioner Ron Paterson says one patient lost his left eye, one had a stroke while waiting for an appointment for surgery in Wellington, and another man's prostate cancer went untreated.
He says all these patients were lost in the health system.
Mr Paterson says the cases highlight the need for a consistent, electronic national system for handling referrals between district health boards.
He wants the director-general of health to let him know by late March what systems there are at all district health boards for handling these referrals.
However, the Ministry of Health's principal medical adviser, David Galler, says the development of such a system would be complex and could take some time.
Mr Galler admits the incidents highlighted by Mr Paterson are concerning, but says hospitals deal with a huge number of referrals reasonably well.
He says work is being undertaken by the ministry to build safer, more standardised, systems within the health sector.
Man loses eye
Mr Paterson says it beggars belief that a patient with a serious, treatable health problem can be lost in a modern health system in such a way.
The case involved a Northland man, aged in his mid 40s, who noticed that he had a shadow over his left eye when he was driving home one day.
He was seen by his family doctor who suspected a detached retina and referred him to Whangarei Hospital. He was seen there and referred to Auckland DHB's ophthalmology department in August 2006.
Ten days later, having heard nothing, the patient had his GP contact Whangarei Hospital, which called Auckland who said they had the referral.
The operation should have been done within two weeks, but the man still heard nothing about an appointment.
Six months later, he complained again and got the appointment, but it was too late. The detached retina could not be repaired, and his eye was removed.
Mr Paterson says the case went into "a black hole" for six months.
He says there are two booking systems at Auckland: a centrally co-ordinated one for non-urgent referrals and another for urgent cases. It went through the latter but was misfiled because of an "administrative error".
The DHB admits it failed the patient, but says it was an isolated case.
'No record' of stroke victim's referrals
The second case involved a man, 72, who had had a small stroke. He was from the Palmerston North area and needed surgery to a narrowed neck artery that is not performed there.
A referral letter was sent twice to the Capital and Coast DHB but it has no record of having received either.
While the man was waiting, he had a second, more serious stroke in November last year.
His son says his father is now severely disabled. Radio New Zealand's health correspondent understands the man needs fulltime care.
Mr Paterson says family was badly let down by both DHBs, and they have an ethical responsibility now to ensure that the man gets the right care.
Cancer victim forced to wait 6 months
The third case involved a man in his 70s who had undergone a blood test for prostate cancer.
He was also affected by a misplaced referral by Counties-Manukau DHB.
The man was told he should be seen within four to six weeks, but was kept waiting up to six months.
He was finally diagnosed with prostate cancer which had spread. He is now very unwell.
